Provider Demographics
NPI:1033144001
Name:MARCELLINO, BERTHA (MD)
Entity Type:Individual
Prefix:
First Name:BERTHA
Middle Name:
Last Name:MARCELLINO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2860 S OCEAN BLVD APT 509
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33480-5562
Mailing Address - Country:US
Mailing Address - Phone:561-586-5083
Mailing Address - Fax:
Practice Address - Street 1:3003 S CONGRESS AVE
Practice Address - Street 2:SUITE 1C
Practice Address - City:PALM SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33461-2169
Practice Address - Country:US
Practice Address - Phone:561-433-3460
Practice Address - Fax:561-433-3828
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92093207QA0505X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL272165100Medicaid
FL272165100Medicaid
FLU4425WMedicare PIN